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Objective To explore the effects of low ligation of the inferior mesenteric artery (IMA) on the third station lymph node dissection in laparoscopic radical resection of rectal cancer (RC),and analyze the risk factors affecting the third station lymph node metastasis.Methods The retrospective cohort study was conducted.The clinical data of 380 RC patients who were admitted to Renji Hospital of Shanghai Jiaotong University School of Medicine from June 2014 to June 2016 were collected.Of 380 patients,177 with preservation of left colic artery (LCA) and 203 without preservation of LCA were respectively allocated into the low ligation group and high ligation group.All the patients received laparoscopic radical resection of RC based on the principle of total mesorectal excision (TME).Observation indicators:(1) intra-and post-operative recovery situations;(2) results of postoperative pathological examination;(3) follow-up and survival;(4) risk factors analysis affecting the third station lymph node metastasis.Follow-up using outpatient examination and telephone interview was performed to detect postoperative disease-free survival and tumor recurrence or metastasis up to May 31,2017.Measurement data with normal distribution were represented as x ± s,and comparisons between groups were evaluated with the t test.Comparisons of count data and ordinal data were respectively analyzed using the chisquare test and U test.The survival curve and survival rate were respectively drawn and analyzed using the KaplanMeier method,and the survival analysis was done by the Log-rank test.Results (1) Intra-and post-operative recovery situations:all the patients underwent successful surgery.The operation time,time to initial exsufflation and cases with anastomotic leakage were respectively (147.2±3.0) minutes,(72.8± 1.4)hours,20 in the low ligation group and (137.2±2.8) minutes,(76.6± 1.1) hours,38 in the high ligation group,with statistically significant differences between groups (t =2.463,2.073,x2 =4.025,P＜0.05).Volume of intraoperative blood loss,cases with temporary stoma,vascular injury (injury of inferior mesenteric vessels and presacral vein injury),urinary retention and duration of postoperative hospital stay were respectively (119±6)mL,25,29,24,(10.7± 0.5)days in the low ligation group and (108±5)mL,32,27,30,(9.6±0.4)days in the high ligation group,with no statistically significant difference between groups (t=1.524,x2 =0.235,0.716,1.115,t=1.780,P＞ 0.05).Of 58 patients with anastomotic leakage,31 received previously terminal loop ileostomy,13 received conservative treatment and 14 received postoperatively terminal loop ileostomy.Fifty-four patients with urinary retention received urethral catheterization.All the patients with complications were improved by treatment and then were discharged.(2) Results of postoperative pathological examination:number of lymph node dissected in the low ligation group and high ligation group was respectively 12.8±0.4 and 12.0±0.3;cases with depths of tumor invading to intestinal wall in stage pT1-T2 and pT3-T4,with tubular adenocarcinoma and non-tubular adenocarcinoma,with high-differentiated,moderate-differentiated and low-differentiated tumors,with lymph node metastasis in stage N0,N 1 and N2,with and without the third station lymph node metastasis,with TNM staging in stage Ⅰ,Ⅱ,Ⅲ,and Ⅳ were respectively 53,124,150,27,81,63,33,73,66,38,16,161,17,54,93,13 in the low ligation group and 59,144,176,27,99,59,45,79,78,46,24,179,32,47,105,19 in the high ligation group,with no statistically significant difference in above indicators between groups (t =1.556,x2 =0.035,0.296,U=2.002,0.220,x2 =0.778,U=5.557,P＞0.05).(3) Follow-up and survival:338 of 380 patients were followed up for 6-36 months,with an average time of 28 months,including 164 in the low ligation group and 174 in the high ligation group.The 1-and 3-year disease-free survival rates and cases with postoperative tumor recurrence or metastasis were respectively 93.9％,76.4％,39 in the low ligation group and 94.8％,79.3％,36 in the high ligation group,with no statistically significant difference between groups (x2=0.861,P＞0.05).(4) Risk factors analysis affecting the third station lymph node metastasis:results of univariate analysis showed that tumor location and diameter,depth of tumor invading to intestinal wall and tumor histopathological type were related factors affecting the third station lymph node metastasis of RC patients (x2 =9.957,9.921,6.196,6.576,P＜0.05).Results of multivariate analysis showed that tumor diameter ＞ 5 cm and non-tubular adenocarcinoma were independent risk factors affecting the third station lymph node metastasis of RC patients (Odds ratio=2.561,2.296,95％ confidence interval:1.280-5.123,1.037-5.083,P＜0.05).Conclusions The low ligation of the IMA is safe and feasible in laparoscopic radical resection of RC,meanwhile,it has the same radical effect in lymph node dissection and doesn't affect the third station lymph node metastasis and shortterm disease-free survival compared with high ligation of the IMA.Tumor diameter ＞ 5 cm and non-tubular adenocarcinoma are independent risk factors affecting the third station lymph node metastasis of RC.
ABSTRACT
Crohn's disease(CD)is a chronic non-specific intestinal inflammatory disease,and the incidence of perianal fistulizing CD(PFCD)is 17%-43%. Non-cutting setons is the first choice for surgical treatment of PFCD. Some new surgical methods are effective for specific types of PFCD,however,the efficacy of most new methods remains to be confirmed by further studies. The multidisciplinary team(MDT)mode has become a new direction of PFCD surgery. This article reviewed the advances in surgical treatment of PFCD.
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Background:Studies have shown that Houpupaiqi mixture is beneficial to the recovery of postoperative gastrointestinal function in patients undergoing open gastrointestinal surgery. However,there is no randomized controlled trial focusing on the efficacy of Houpupaiqi mixture on laparoscopic colorectal cancer patients. Aims:To investigate the efficacy of perioperative administration of Houpupaiqi mixture on fast track surgery in patients with laparoscopic colorectal cancer. Methods:A total of 170 colorectal cancer patients at Renji Hospital from January 2016 to February 2017 were enrolled into the prospective randomized double-blind controlled clinical trial. The patients were randomly divided into experimental group and control group,and Houpupaiqi mixture(50 mL)or placebo(50 mL)were administered 6 hours before surgery, as well as 6 and 12 hours after surgery,respectively. The clinical efficacy and safety were compared between the two groups. Results:The patients in experimental and control groups were well balanced with respect to the baseline characteristics. Compared with the control group,time to first anal exhaust,time to recovery of regular bowel sounds and time of postoperative hospital stay were significantly decreased in experimental group(P<0.05). However,no significant differences were observed in first time to defecation,first time to drink,first time to eat fluid diet and first time to eat solid food between the two groups(P>0.05). One patient with anastomotic fistula was found in each group. Conclusions:Houpupaiqi mixture significantly promotes the recovery of gastrointestinal function of patients undergoing laparoscopic colorectal cancer surgery,with reduction of time to recovery of regular bowel sounds,time to first anal exhaust,and shortening the postoperative hospital stay,which is in favor of rapid rehabilitation.
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<p><b>OBJECTIVE</b>To investigate the efficacy of complete mesocolic excision (CME) in the radical operation for right hemicolon cancer.</p><p><b>METHODS</b>Clinical data of 336 cases of right hemicolon cancer undergoing radical resection, including 218 cases of CME surgery group and 118 cases of traditional surgery group, from January 2005 to December 2014 in Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University were retrospectively analyzed. Intraoperational events, perioperative status and postoperative survival were compared between the two groups.</p><p><b>RESULTS</b>The baseline information was not significantly different between the two groups (all P>0.05). The number of harvested lymph nodes in CME and traditional group was 11.4±0.3 and 9.3±0.5 respectively(P=0.000) and the proportion of greater than or equal to 12 lymph nodes per case was 47.3%(103/218) and 28.8%(34/118)(P=0.002), which both were significantly different. The operation time in CME and traditional group was (147.2±2.9) and (148.8±3.9) minutes, which was not significantly different (P>0.05), whereas operative blood loss was (125.7±7.5) and (305.1±20.5) milliliters in CME and traditional group with significant difference (P=0.000). Postoperative hospital stay was (12.9±0.9) and (16.3±1.0) days in CME and traditional group with significant difference (P=0.018), while the time to postoperative liquid intake and normal diet was not significantly different between two groups (both P>0.05). The morbidity of postoperative complication of CME group was lower compared to traditional group (14.2%, 31/218 vs. 24.6%, 29/118), which was significantly different (P=0.018). Among them, infection occurred in 19 (8.7%) cases and 21 (17.8%) cases with significant difference between the two groups (P=0.014). The average time of follow-up was (34.5±1.2) months and (27.9±1.5) months in CME and traditional group, and the five-year survival rate was 85.6% and 78.0% with significant difference(P=0.043). Moreover, 102 cases underwent laparoscopic-assisted CME and 116 cases underwent open CME in CME group. The 5-year survival rate was 89.8% and 82.2% in laparoscopic and open group with significant difference (P=0.048).</p><p><b>CONCLUSION</b>Compared with traditional radical resection, CME radical resection for right hemicolon cancer can harvest more lymph nodes, decrease operative blood loss, lower the riskof postoperative complication, shorten the postoperative hospital stay, and increase the 5-year survival rate. Furthermore, laparoscopic-assisted CME has more advantages.</p>